More than a patient; a person blog series - Kathy Torpie

One of the challenges to ensuring that those receiving medical treatments feel/see themselves as more than patient is lack or poor team work from healthcare professionals- this is common in care services. The effect of poor team work often result in those receiving treatment lacking confidence and trust, leading to confusion or agitation.

This barrier can only be removed by collective person centred objective and individual responsibility for duty of care.
In addition, apart from the medications, the trainings, available resources, "caring" should be seen as part of the treatment.

The products or services that help those receiving medical treatments to feel/see themselves as person is Day Centres because aspirations, skills and abilities are discovered

HI. The words also apply to those receiving support in the community. I have recently been concerned about the support that my mother is receiving. She has leg ulcers and is being treated by a series of community nursing staff, all of whom seem to have different views on what is right and all have different approaches. Although she is in her 90's Mum is still an intelligent woman who knows her own body and experiences the same frustrations as all of us. There are times when the nurses speak to her as if she was a- a child - who needs to be told what to do, "if I say you will, you will"; or is deliberating delaying health improvement - "this is taking far too long to heal". It seems to me that part of the problem is that there is no consistency of treatment, redness around the wound area, has so far been labelled, infection; eczema; allergic reaction; -on consecutive days by different individuals. Mum attempts to communicate what others have said, but to no avail, and she is rapidly reaching the point where she is going to start refusing treatment, which is not a decision I would be happy about her taking. Like many people of her generation she feels that she cannot complain, because it will a- do no good, and b- serve to get her into trouble. I am finding it hard because I don't want to react as if she isn't a capable woman able to make decisions, if given the right information.
Sorry feel better for having got that off my chest. If you want to use this as a case study, or even a blog post feel free. Thanks for letting me talk.

Person Centred Care is an ideal philosophy for delivering individual services to each client, still yet we strive for this and Government Policy dictates this is the way forward without the appropriate funding to make this a reality.
We can have as many meetings as we want and involve as many people as we want anything can be written on paper it is the action that drives this forward, for years we have heard of joined up working practice and still inter agency working is fragmented with different professionals working against each other and not seeing that we are all in the process, less individual self importance is so negative the most important person is the client , the receiver of the service.
Todays training of nurses and care professionals has produced an over abundance of robotic individuals who lack the simple ability to actually CARE.

Kindness, respect and compassion are things we give freely - they cannot be bought. Many 'vision statements' or 'values' of organisations, and job descriptions, feature such words, but what really makes a difference still, is the personal experience and relationship. One small change which may make a difference, is for us all to stop referring to people as 'patients', 'service users' or 'clients'. Yes their is a professional relationship in terms of a specific function or service, but how that service is delivered reflects such things as kindness...

Thank you for these replies to the post - it is great to hear other opinions. There is no doubt that there is so much will and drive to change the experience of those undergoing medical treatment but the reality of bringing those changes about often feels like going round in circles. Liz Taylor - thank you for your personal experience in sharing what you and your mother are going through. I had similar frustrations through my own mothers years of treatment, and she would often feel that her wishes, fears, or experiences seemed to be the last thing any of her carers were interested in. That said there were also occasions of exceptional care. If you would be happy to take part in the blog series Liz please do drop me an email to [log in to view email address] so that we can share these experiences of yours as a loved one who is caring for somebody - each of these perspectives are so important to be understood for us to bring about some sort of call for change.

Hi Liz,

Re:

'She has leg ulcers and is being treated by a series of community nursing staff, all of whom seem to have different views on what is right and all have different approaches.'

I'm not at all sure that this will be useful - but. I came across something about leg ulcers last year. In essence, it amounted to 'if they are not healing, then you might benefit from specialist intervention'.

The essential point, was that often leg ulcers refuse to heal unless 'what is going on 'underneath'' (deeper in the leg) is investigated and treated as well as the 'surface' (the ulcerated skin which you can see). What I read, suggested that some people with leg ulcers which had not healed for months, had their ulcers healed within a relatively short time when they were sent for treatment at specialist ulcer clinics, where the staff are really expert. Often 'the skin is treated, without considering why the skin is in bad shape' - the 'experts' will consider things more deeply than a typical community nurse, for example.

It might be worth asking - or doing some internet searching - to see if there is a specialist leg ulcer clinic in your mum' area ? I'm not at all confident that this will help.

This is a cogent response to, and an accurate reflection of, the status-quo.

In your opinion, is it important that those receiving medical treatment, see/feel themselves, and are seen by others, as "more than a patient; a person"? If yes: why? (If no: why not?)

Answer: Without question. It's by giving and acknowledging the patients name and identity, race, religion, sexuality and gender, and age that we acknowledge that person and can start with respect and maintaining dignity when someone is sick and at their most vulnerable

Based on your experience, what is the greatest challenge of ensuring that those receiving medical treatment feel/see themselves, and are seen by others, as "more than a patient; a person"? And, why?

Answer : The greatest challenge is recruitment and selection. Too often we take people on in sensitive areas of work that do not ' have the innate skills or ability to care or be compassionate. They may have head knowledge and technical prowess, but they don' have what it takes to make the difference.

What do you think needs to be done to improve this Concretely, what product/s, service/s or action/s help those receiving medical treatment to feel/see themselves, and be seen by others, as "more than a patient; a person"?

Answer: As above. Improve recruitment and selection and training. Ensuring the appointment of pastoral carers on the wards would be my idea of moving things forward constructively and introducing reflective supervision so that staff can improve on insight, interpersonal and relational skills, patient contact.

What changes has your organization made to ensure that those receiving medical treatment feel/see themselves, and are seen by others, as "more than a patient; a person"? And what impact have they had?

Answer: I am based in one agency which interfaces with clients accessing medical care and coming into contact with the medical profession . Wherever we sit it is about challenging discrimination and language which makes assumptions. Modelling and reinforcing dignity and respectful practice. Maintaining a patient's confidentiality. The impact has been better engagement from service users, but a few ruffled feathers amongst professionals who don't want to change or don't feel they need to change.

Hi Claire, I took some time to answer your questions to a very important topic raised about patients and dignity . I couldn't send by your personal email as it was incorrect .

In your opinion, is it important that those receiving medical treatment, see/feel themselvesIn your opinion, is it important that those receiving medical treatment, see/feel themselves, and are seen by others, as "more than a patient; a person"? If yes: why? (If no: why not?)

Answer: Without question. It's by giving and acknowledging the patient's name, identity, race, religion, sexuality and gender, and age, that we begin to relate and to acknowledge that person as an individual rather than a patient or number . This then helps us to maintain respect and dignity when someone is sick and at their most vulnerable.

Based on your experience, what is the greatest challenge of ensuring that those receiving medical treatment feel/see themselves, and are seen by others, as "more than a patient; a person"? And, why?

Answer : The greatest challenge is recruitment and selection. Too often we take people on in sensitive areas of work that do not have the innate skills or ability to care or be compassionate. They may have head knowledge and technical prowess, but they don' have people skills or what it takes to make the difference in restoring health.

What do you think needs to be done to improve this Concretely, what product/s, service/s or action/s help those receiving medical treatment to feel/see themselves, and be seen by others, as "more than a patient; a person"?

Answer: As above. Improve recruitment and selection and training. Ensuring the appointment of pastoral carers on the wards would be my idea of moving things forward constructively and introducing reflective supervision so that staff can improve on insight, interpersonal and relational skills in their patient contact.

What changes has your organization made to ensure that those receiving medical treatment feel/see themselves, and are seen by others, as "more than a patient; a person"? And what impact have they had?

Answer: I am based in one agency which interfaces with clients accessing medical care and coming into contact with the medical profession . Wherever we sit it is about challenging discrimination and language which makes assumptions. Modelling and reinforcing dignity and respectful practice. Maintaining a patient's confidentiality. The impact has been better engagement from service users, but a few ruffled feathers amongst professionals who don't want to change or don't feel they need to change.

What do you think needs to be done to improve this Concretely, what product/s, service/s or action/s help those receiving medical treatment to feel/see themselves, and be seen by others, as "more than a patient; a person"?

Answer: As above. Improve recruitment and selection and training. Ensuring the appointment of pastoral carers on the wards would be my idea of moving things forward constructively and introducing reflective supervision so that staff can improve on insight, interpersonal and relational skills, patient contact.

What changes has your organization made to ensure that those receiving medical treatment feel/see themselves, and are seen by others, as "more than a patient; a person"? And what impact have they had?

Answer: I am based in one agency which interfaces with clients accessing medical care and coming into contact with the medical profession . Wherever we sit it is about challenging discrimination and language which makes assumptions. Modelling and reinforcing dignity and respectful practice. Maintaining a patient's confidentiality. The impact has been better engagement from service users, but a few ruffled feathers amongst professionals who don't want to change or don't feel they need to change.

Safeguarding manager

I'll extract the questions from Linda's response, and see how I would answer them: I'm not sure that I'm the right person to answer this one, and I'm currently a bit occupied re my online time, but I've got a few minutes at the moment.

In your opinion, is it important that those receiving medical treatment, see/feel themselves. In your opinion, is it important that those receiving medical treatment, see/feel themselves, and are seen by others, as "more than a patient; a person"? If yes: why? (If no: why not?)

ANSWER: It probably depends on what the treatment is for - my instinct is that the answer is 'yes' for long-term treatments, for mental health issues, and for things such as treatment of 'frailty in the elderly', for example, but not so much for brief treatment of acute illness/injury. The 'why' would be because those treatments/interventions are not likely to be successful, unless the patient 'properly engages'.

Based on your experience, what is the greatest challenge of ensuring that those receiving medical treatment feel/see themselves, and are seen by others, as "more than a patient; a person"? And, why?

ANSWER: I have no relevant experience to answer this.

What do you think needs to be done to improve this Concretely, what product/s, service/s or action/s help those receiving medical treatment to feel/see themselves, and be seen by others, as "more than a patient; a person"?

ANSWER: In fact, our law [for 'consent to treatment/intervention'] IS based on 'people being individuals' so, it would help if the professionals understood and accepted the Mental Capacity Act. However, this - accepting that patients and service users are all individuals within a specific external situation, and cannot be treated just on the basis of that situation - is much more intensive in resource terms, and much more challenging in 'organisational terms', than what often happens (not treating people as individuals). This is in essence what I recently wrote about here on DIC in my piece 'Mike's Cheeky Blog: people are not like tins of baked beans, because people are all individuals'. The editor of the BMJ, Fiona Godlee, recently pointed out that while a lot is written about patient-centred care, that is not what the system currently provides, in her paper 'At your next conference ask where the patients are'. You can download her paper here:

http://www.bmj.com/content/bmj/354/bmj.i5123.full.pdf

Fiona Godlee started her paper with:

'It may not feel like it just now, but what we have is doctor centred care. Perhaps also institution, manager, and nurse centred care. What we don't yet have is patient centred care, despite this being obviously what healthcare should be. But things are slowly shifting in the right direction, and The BMJ aims to help keep up the momentum.'

What changes has your organization made to ensure that those receiving medical treatment feel/see themselves, and are seen by others, as "more than a patient; a person"? And what impact have they had?

ANSWER: again, I am not in a position to answer that

A resident I care for, has just passed away but my senior has told me not to bother dressing her.... but I feel disgusted about it, yes she was just a resident in here, but she is also a human being and we could of atleast preserved the dignity of her, I actually feel horrible about it :/

Hi Anna,

I think your senior is way out-of-line - 'dignity' does not stop with death.

All of the nursing guidance I have ever stumbled across about immediate post-mortem behaviour, places an emphasis on what you might describe as 'the dignity of the deceased'.

If the alternative to dressing the body, is something like covering it with a sheet, then that doesn't seem 'as dignified' to me - although I would probably need more details [about 'what happens next'] to be sure about this.

In any event, the fact that you feel horrible about it, should be discussed 'by your place of work'.

Thank you for posting this, I hope your post gets some responses.

HI Anna I am sorry you have had to experience this. You are absolutely right, we should treat every human being with respect and for me that means at the point they leave this life as much as when they are an active part of it. All the end of life training and reading I have every done makes it clear that respect and consideration at death are as important as in the hours leading up to it.. I will also put this comment on the discussion forum. Liz

She was just left in bed with the door wide open I had to close the door and when I went back down her door was open again..... it was my first resident I care for to pass so it was quite hard for me to deal with, I know it's part of life and it's happens to everybody but that's not the point, the residents on the unit are up and down wandering around constantly aswell sos he would of been seen.

Hi again Anna,

The fact that it is the first time for you, almost certainly affects your feelings.

'Death' is incredibly complicated, emotionally and legally. I think you are right about the door - I can't see why it should be left open. Although, if other residents who knew this lady wanted to visit her bedside to 'pay their last respects' (not the clearest phrase - I'm not sure what would be both concise and comprehensive there) then I think they should be allowed to do that: which equates to 'I suspect that deaths 'shouldn't be hidden''.

We - modern society - are no very familiar with death. I read a piece by a nurse once, who was describing how 'unsettling' (my word) her first interaction with a deceased person was. I read another piece by a different nurse, who ran over a rabbit and killed it when driving home from a night-shift: she broke down in tears at home, and she couldn't work out why - she wrote that she comes across death all the time in her job, so she couldn't understand why the death of a rabbit upset her so much.

People are reluctant to even talk about dying and death - we all have different personal experiences and our own 'ways of thinking', so together that makes most things to do with death very 'awkward to handle'.

I was with both of my parents, when they died - I cannot rationalise why I felt the way that I did on those two occasions [so I would never attempt to try and 'understand' how anybody else was feeling], and I also found a cousin dead in his home, which was also 'strange in unexpected ways': all I can say, is that in my opinion all deaths are different.

I understand other residents paying respect, but the residents are all dementia residents and end up walking around the corridors naked and what not and they have a tendency to just stand and stare at you, it slightly unsettling when it's the middle of the night and as I'm doing my rounds they are all just stood in the corridor looking at me, scary, but they also wander in and out of other people's rooms, so it was hard for me, the lady's family had been to say goodbye and so had the doctor, it was a case of waiting for the funeral people to come and get her and that alone took 3 hours, so I don't understand why the door was open and when I closed it, it was open again :/

I love my job and I love what I do but I just feel like all dignity was thrown out the window that night.

Hi again Anna,

Thanks for the longer explanation. But it isn't clear who was re-opening the door - was that 'wandering residents' or was it 'staff': it is a difficult situation.

Dementia is a horrible illness. But I think that however unsettled you are by the behaviour of your residents with dementia, the residents are even more unsettled - they are living in a world which probably makes no sense to them, and is utterly 'confusing' to the point of being terrifying for some of them.

As you say 'the lady's family had been to say goodbye and so had the doctor' the remaining question, hinges on whether any of the other residents would have felt the need to 'pay last respects' - which is affected by the 'dementia issue'. If there was a reasonable expectation that nobody else would be doing that, perhaps the door should have been locked [if that is possible] until the funeral people arrived ? It looks like the homes policy might need a re-think, or perhaps the policy needs to be properly explained to you ?

I'm pleased that you have this concern about the dignity of the residents - best wishes, Mike.

I think residents families are very important to us as carers they really need a lot a lot of support at a difficult time .

Dementia is a terrible illness my nan was diagnosed with it but sadly she passed away with other health problems.

I still think about her and miss her so much as she deteriorated very quick.

Hi

Contact your local Tissue Viability Team in your area. You can google it. They will help with a wound care and pressure sore management plan that the community nurses will have to follow.

Thanks a lot, I've given it a try and requested a referral to the Tissue Viability nurse, will just have to wait and see what happens next.

Liz

A person who works in the care industry or health service is an individual wanting to help others with the best of intentions, and training. However, the health service and care industries do not always look after or support their workers who are the backbone of the service within the industry they are trying to provide, not the managers who issue constant cutbacks in hours and overtime, therefore spreading the individual worker's time very thinly.

This is when the personal touch in care or health services can sometimes be lost.

Hi Christine,

You might be interested in something Professor David Oliver recently wrote on much the same theme at:

http://www.bmj.com/content/356/bmj.j146

He titled his piece 'David Oliver: Is NHS "candour" on a break for winter?' and he opened it with:

'Winter seems more difficult each year in NHS acute care, and 2016-17 is no exception. Vocal public support from national leadership bodies would be a welcome New Year gift. It would certainly beat attempts at news management to limit reputational damage and appease politicians' reported wishes to keep hospital crises out of the headlines.'

A line later in the piece is:

'Trapped in the middle are frontline staff under almost unbearable pressure-the King's Fund's Chris Ham refers to them as "shock absorbers."'

I have always spoken to my patients when either asleep or awake. I think that they get comfort with each conversation because you really don't know how they are feeling in that moment of time. The same goes with patients with dementia I always hold their hand and smile at them when I am talking to them just because they cannot hold a conversation with you to see that smiling face and holding their hand must give them some comfort.

Hi I know exactly what you mean, The problem is each nurse has their own opinion and they think it's the right one, I am sorry to read that your mum is thinking of stopping the nurses attending to her need's. I think that if you were to speak to your mum's GP and explain as to what is happening hopefully they can find a answer to the problem because at the end of the day your mum need's attention.

I agree the workers are the back bone of the industry.
I'm a full time support worker looking after people with mental health problems and learning disabilities.

I work 13hour shifts in the day,and night shifts
But I absolutely love my job looking after and caring for this lovely people.

I think the best thing I have heard in the press lately regarding care homes is the fact that there is a suggestion for the NHS to take over failed care homes. I can't think of anything better that could happen and it should prove successful for the future.

I hope that plan for the NHS to take over failed care homes goes ahead.
We need more of them.

Unless I'm mistaken, there is not any plan for the NHS to take over failed care homes.

I believe that Jeremy Corbyn said that is something 'he would do' but as he is not the government, that is not the same as something likely to happen.

As I understand it, a few decades ago there were many more care homes operated by local councils - these were mainly replaced by privately-owned care homes within the last couple of decades, I think 'on cost grounds' [although those cost grounds might have been represented as 'efficiency grounds'].

Should Lucozade be provided in care homes as a matter of course like tea or coffee.

Would welcome your view.

Hi hope I have come to the right place ,
You was asking if Lucozade should be offerd in care homes the same has Tea & Coffee .
My care home we offer a massive selection of drinks
IE: Lemonade,Coke, Flavoured Water ,Horlicks ,Hot Chocolate that's just a few ,We find this works really well & you got to think not everyone like Tea of Coffee & after all this is there home so why shouldn't they have what they want ,
Could you imagine if you couldn't get a drink that you really like it would be awful .
Were is the Dignity & Respect in that ?
A little bit of comfort of there old life goes a long way to our residents.

Re the Lucozade topic,
How long is a piece of string, in my experience most care settings offer a variety of fluids of course choice is always paramount but depending on individual health needs encouragement and promotion of fluid intake is important, how many of us take up the recommended water intake per day that we should?
This is even more important as we get older and our kidneys do not function as well as they used to, there is nothing more natural than water for flushing the system out, yes we all have our favourite drinks and moderation is the key but a lot of these health promoted drinks really do not have any potential health benefits accept some taste good because of the additives in them. How many U.T. Infection occur simply because one does not get adequate fluid input. I think we really need to concentrate on making sure that individuals get regular access to fluids
as i have regularly witnessed drinks given to people who either cannot drink without support or drinks are placed out of reach. There is no excuse for this BUT it still happens. If a person as a liking for a certain drink ie lucozade then yes provide it if possible, the person may prefer to purchase their own supply even. One can only offer a various amount of drinks in any setting.

Agree that people should be offered drinks of their choice and not just standard tea, coffee or squash. However we need to be practical and we cannot have a drinks trolley that contains anything anyone might want. But through discussion it should be possible to offer a range that meets known preferences, without this being overly expensive or difficult to achieve.

In terms of Lucozade, then if its personal preference then why not? We so often make decisions base don our perceptions of what is good [or not] for us, rather than what makes the quality of life for others. I have a personal liking for .Cola and during a spell in hospital it was the ting that I craved above everything else, but was not allowed it. It made me quite miserable, and I really didn't feel that anyone was listening to me.

So respond to choice and preference, none of us can have ultimate choice but we can all be listened to.

I definitely think that more options beyond tea and coffee should be on offer.

I think that the sense of taste often declines with age, and it seems quite possible that sometimes a person who isn't attracted by tea or coffee, might want lemonade, or whatever: it is surely better to try and provide a drink the person is keen on, rather than to try and persuade a person to drink something they are not keen on ?

I agree a person should have the choice of drinks.
If they don't like tea or coffee there should be other options,I know that I know that Lucozade is full of sugar so I really don't know about that one.

Along with many sectors, it is unfortunately true that within the health and social care environment, the financial bottom line is the strongest driver in how services are delivered (and, indeed, whether those services are delivered or not). All too often, care is delivered to suit the needs of the institution rather than the needs of the person, which should be the primary driver to good quality care.
Tight financial restraints mean that many carers are poorly trained and poorly paid without any autonomy to input their own empathy towards the people they care for.
We hear so much bad news about poor provision of care, but not so much is heralded when excellence is achieved. Rather than concentrating on poor care provision, steps should be taken to encourage small, sequential steps to successful person centred care, rather than trying to make sweeping changes which would seem unattainable.
While all of us would prefer to be self-reliant, being in a position to require medical or social care may not be our preferred option, but it should not lead to de-humanisation and institutionalism.

Ken Nicholas has pointed out:

'Tight financial restraints mean that many carers are poorly trained and poorly paid without any autonomy to input their own empathy towards the people they care for'

Unless carers are allowed to 'input their own empathy' - which I think can be translated as 'are actually allowed to care !' - the better carers will be frustrated, and the people being cared for will probably be less satisfied with the care they are receiving. Money has probably got something to do with that - but I feel sure that 'process and record-keeping' also plays a part.

I don't think its about "tight financial constraints" or " poorly trained care staff". Sometimes care staff just want to give up. You just look at someone wrong these days and you get reported.
There is TOO MUCH red tape. I agree you should have policies and procedures, but companies are so terrified about going/getting taken to court, that they have forgotten what this whole story is all about.
Now, carers just do their shifts and go home. NO extra time, extra care, extra volunteering, nothing. All that motivation, drive and will has been broken by management, rude families and law.
Until you stop breaking the willing horse, you wont get willingness to succeed, willingness to train, willingness to do that little bit more.

Unfortunately the care sector with elderly has always been poorly paid, unless you actually work for social services.

In all my years ive seen the policy and procedures change and yes for the better.

Although if carers give up the question is should they continue in there role.

Ive seen it ive heard it mayb its time people either change jobs or actually realise giveing up is not a solution they have just given in so i continue to smile and be proud of the residents everyday or when im on shift i learn something new. The goverment need to be addressed about the pay not the establisment we work for.

Regards to all who read ??
Debbie

Hi, Debbie,

I'm a support worker I also Learn something new everything day.
Yes I agree they should address the but they probably won't.

Kind regards,

Tracy.

Thank you Tracy
Im studying at Uni also so being the oldest in class the conversations can be about work and working in the care sector.
Im amazed how naive some of the students are when it comes to the elderly..

Out of sight out of mind attitude

Hi Debbie,

Thank you for your email.
I started my job in June looking after people with mental health problems and learning disabilities.

You have to listen and learn that is what I've done,as I never worked in health and social care before

Do your best that's all you can do good luck with your studying
?? .

Kind regards.

Tracy

Thanks Tracy Fellows.

I have a question prior to starting your shift and this will go to everybody reading do you do a warm up exercise.... yes this is a project im looking into to develope for my degree i would be interested to hear from all staff personel admin and care sector

Happy Sunday

Debs

Hi Everyone - Just a quick up date on my Mum. We did eventually get a vascular nurse out and she gave some really good advice, which when followed produced a major improvement in my Mum's leg ulcers. However unfortunately following attendance by one nurse who didn't follow the instructions we are back to square one. So frustrating for Mum. It seems that because she is old, there is an assumption by some that she doesn't know what she is talking about, and when she tries to give advice or tell a nurse that they are not following the right instructions she is ignored at best, or at worst told that she should leave it to the professionals.
I am finding it increasingly hard to adhere to my Mum's wishes not to make a complaint, as the majority of the staff are really good, but the damage caused by the small [very] minority who do not treat her with respect and dignity is incalculable.
Will keep you posted as tings develop.

Hi Liz,

I understand your mum's reluctance to make a formal complaint, and I suspect that the following is both fairly common, and also 100% unacceptable:

'It seems that because she is old, there is an assumption by some that she doesn't know what she is talking about, and when she tries to give advice or tell a nurse that they are not following the right instructions she is ignored at best, or at worst told that she should leave it to the professionals.'

I am no expert on these ulcers, but I feel sure they fall in the 'much longer to fix than to create/worsen' category, which only adds to your frustration - you don't need most of the nurses to get it right, you essentially need all of them to get it right, to make progress with the leg ulcers. Might your mum consider letting you have a word with her GP, in which you point out that she doesn't want to make a formal complaint, but that you have noticed that most of the nurses are following the specialist nurse's advice/plan and her ulcers then improve until the odd nurse departs, and destroys the progress ?